Whee Sung Son

doi:10.12701/jyms.2025.42.64

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Management of a complex tibial fracture in a patient with Prader–Willi syndrome and severe obesity: Whee Sung Son; Journal of Yeungnam Medical Science 2025;42:64.
DOI: https://doi.org/10.12701/jyms.2025.42.64
Published online: October 13, 2025

Department of Orthopaedic Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea

Corresponding author: Whee Sung Son, MD, PhD Department of Orthopaedic Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, 170 Hyonchung-ro, Nam-gu, Daegu 42415, Korea Tel: 82-53-620-3640 • Fax: +82-53-620-3640 • E-mail: oswsson@gmail.com

• Received: September 18, 2025 • Revised: September 30, 2025 • Accepted: October 4, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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A 24-year-old male was referred to our clinic with left lower leg pain after falling. Radiography and computed tomography revealed a complex tibial fracture originating from the diaphysis and extending distally into the intraarticular region with coronal plane splitting (Fig. 1). The patient had a confirmed diagnosis of Prader–Willi syndrome (PWS) established by cytogenetic analysis at another university hospital, a disease characterized by short stature, obesity with reduced lean mass, increased fat mass, and osteoporosis [1,2]. The patient’s height, weight, and body mass index were 152 cm, 140 kg, and 60.6 kg/m², respectively, consistent with severe obesity. Bone densitometry revealed osteoporosis with a T-score of −2.6. Aside from medication for hyperlipidemia, the patient was not taking any other drugs and was under consideration for partial gastrectomy due to severe obesity.

Fracture management in patients who are severely obese is challenging. Given the need for a fixation construct that can withstand excessive body weight, metal failure and destabilization are common [3,4]. Cast immobilization is often inappropriate because of a large leg circumference, whereas prolonged immobilization should be avoided because of the increased risk of venous thromboembolism [3]. Furthermore, these patients are at an inherently increased risk of infection, with the requirement for deeper approaches and larger incisions in open surgery further augmenting this risk [4]. Patients with PWS present further challenges. Beyond severe obesity, PWS is frequently associated with osteoporosis, poor impulse control, diminished pain sensitivity, and behavioral problems such as oppositional or compulsive behaviors [5]. These features complicate both surgical and nonsurgical orthopedic management, leading to a higher risk of delayed diagnosis, nonadherence, and wound complications. In particular, diminished pain sensitivity may obscure clinical symptoms of fixation failure or secondary injury, whereas behavioral disorders, such as skin picking, can directly compromise wound healing. Consequently, adherence to partial weight-bearing instructions is especially difficult [1], and the construct in this patient needed to withstand full weight-bearing under excessive body weight while minimizing soft tissue complications.

To address these challenges, an intramedullary nail, which is minimally invasive, allows load-sharing, and permits early weight-bearing, was selected as the main construct. However, supplementary fixation was required because the intramedullary nail alone could not provide sufficient stability for the distal intra-articular split. First, the distal intra-articular fracture was reduced using a 5-cm anteromedial approach. Fixation with a 3.5-mm cannulated screw was attempted as a lag screw; however, owing to insufficient stability related to PWS-associated osteoporosis, rim plating was added to secure the distal intra-articular fracture (Fig. 2A). The diaphyseal fracture was then addressed in a minimally invasive technique through stab incisions with a pointed bone clamp and bone hook (Fig. 2A), followed by intramedullary nail insertion via a suprapatellar approach (Fig. 2B–2D).

Ankle range of motion exercises were initiated immediately after surgery, with uneventful wound healing occurring within 2 weeks. Weight-bearing was permitted after 6 weeks, with the expectation that partial weight-bearing would be unachievable. As expected, controlled partial weight-bearing was impossible upon weight-bearing initiation; therefore, full weight-bearing was performed from the outset. Nevertheless, fixation failure and redisplacement did not occur. Partial union was noted on radiography at 3 months, and complete union was observed at 6 months. The patient returned to normal daily activities without complications and remained free of any issues during the follow-up for up to 22 months (Fig. 2E).

Patients with PWS frequently develop fractures because of the combined effects of cognitive disorders, severe obesity, and osteoporosis [5]. Furthermore, despite the complexity of fracture management in these patients, detailed reports on surgical management are lacking. To the best of our knowledge, this is the first report on this topic. Therefore, surgeons should carefully consider the combined challenges of severe obesity, osteoporosis, and behavioral factors when planning surgical strategies for patients with PWS.

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Ethics statement

The patient provided written informed consent for the publication of this report and accompanying images.

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Funding

This study was supported by a 2025 Yeungnam University Research Grant (No. 225A580053).

Fig. 1.

Preoperative (A) plain radiographs and (B) computed tomography images demonstrating a complex tibial diaphyseal fracture extending distally into the intra-articular region with coronal plane splitting.

Fig. 2.

(A) Fluoroscopic images showing distal intra-articular reduction and fixation with a 3.5-mm cannulated screw (Synthes, West Chester, PA, USA) and rim plate (LCP Compact Hand 2.0; Synthes, Oberdorf, Switzerland), as well as percutaneous reduction of the diaphyseal fracture using a pointed bone clamp and bone hook. (B) Intraoperative image obtained after completion of the procedures demonstrating that all steps were performed in a minimally invasive manner. (C, D) Immediate postoperative (C) plain radiographs and (D) computed tomography images. (E) Follow-up plain radiography at 22 months.

References

1. Muscogiuri G, Barrea L, Faggiano F, Maiorino MI, Parrillo M, Pugliese G, et al. Obesity in Prader-Willi syndrome: physiopathological mechanisms, nutritional and pharmacological approaches. J Endocrinol Invest 2021;44:2057–70.Article PubMed PMC PDF
2. Viardot A, Purtell L, Nguyen TV, Campbell LV. Relative contributions of lean and fat mass to bone mineral density: insight from Prader-Willi syndrome. Front Endocrinol (Lausanne) 2018;9:480.Article PubMed PMC
3. Azzam W, Gamal O, Samy A. Treatment of tibial shaft nonunion with a retained nail in morbidly obese patients. Int Orthop 2022;46:1123–31.Article PubMed PDF
4. Pean CA, Rivero SM, Suneja N, Weaver MJ. Severe obesity worsens 30-day surgical outcomes and projected costs in operative femoral shaft and tibial shaft fractures. J Orthop Trauma 2023;37:27–31.Article PubMed
5. Kroonen LT, Herman M, Pizzutillo PD, Macewen GD. Prader-Willi syndrome: clinical concerns for the orthopaedic surgeon. J Pediatr Orthop 2006;26:673–9.Article PubMed

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Figure

Management of a complex tibial fracture in a patient with Prader–Willi syndrome and severe obesity

Fig. 1. Preoperative (A) plain radiographs and (B) computed tomography images demonstrating a complex tibial diaphyseal fracture extending distally into the intra-articular region with coronal plane splitting.

Fig. 2. (A) Fluoroscopic images showing distal intra-articular reduction and fixation with a 3.5-mm cannulated screw (Synthes, West Chester, PA, USA) and rim plate (LCP Compact Hand 2.0; Synthes, Oberdorf, Switzerland), as well as percutaneous reduction of the diaphyseal fracture using a pointed bone clamp and bone hook. (B) Intraoperative image obtained after completion of the procedures demonstrating that all steps were performed in a minimally invasive manner. (C, D) Immediate postoperative (C) plain radiographs and (D) computed tomography images. (E) Follow-up plain radiography at 22 months.

Fig. 1.

Fig. 2.

Management of a complex tibial fracture in a patient with Prader–Willi syndrome and severe obesity